Provider Demographics
NPI:1841488897
Name:BACK IN THE GAME
Entity type:Organization
Organization Name:BACK IN THE GAME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:812-282-4263
Mailing Address - Street 1:1010 WILDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-5429
Mailing Address - Country:US
Mailing Address - Phone:812-282-4263
Mailing Address - Fax:812-288-6441
Practice Address - Street 1:2940 HOLMANS LN
Practice Address - Street 2:STE. B
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-6911
Practice Address - Country:US
Practice Address - Phone:812-282-4263
Practice Address - Fax:812-288-6441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002013A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000230208OtherANTHEM
IN200421930AMedicaid
INDA7238OtherMEDICARE RAILROAD
IN000000230208OtherANTHEM